This weeks’ blog is by Adam Ferner, Child Nursing Student, City St George’s, University of London (adam.ferner@citystgeorges.ac.uk), and considers some of the injustices around EBP.
http://www.adamferner.com/
Evidence-based practice (EBP) is at the heart of modern healthcare. Certainly, there is much to recommend EBP, which involves the integration of the best evidence, clinical experience and patient preference to inform decision-making (Fu et al., 2020). Nevertheless, any system used to generate and organise the ‘best evidence’ can be controversial and should be viewed with caution – and maybe even suspicion. Controversies around what constitutes ‘best evidence’ have been carefully analysed (Hanley et al., 2016). Nurse-researchers are themselves aware of the pitfalls of EBP and some now describe it as containing “epistemic injustices” (Haghiri-Vijeh, 2025), or unfairness relating to knowledge.
Injustices in EBP
Different forms of epistemic injustice are described. A patient can be victim of ‘testimonial injustice’ when they are regarded as unreliable because of a prejudice relating to their identity (Blease et al., 2017). For example, patients with Sickle Cell Disease (SCD) frequently experience testimonial injustice (Dhairyawan, 2024); SCD mainly affects Black and ethnically minoritised people, and staff can be unsympathetic to requests for pain relief because of the racist belief that Black people are more tolerant to pain (Sowemimo, 2023).
‘Hermeneutical injustice’ occurs when the tools (hermeneutics) to interpret patient experience are lacking. For instance, before the diagnostic category “chronic fatigue syndrome” was established, professionals were severely limited in their ability to understand patients; there were also scant resources which patients could use to describe their condition to others (Blease et al., 2017).
Evidence-based practice has, to some extent, acknowledged these injustices and attempted to create more robust research frameworks by increasing patient involvement, and this is to be welcomed. However, such attempts imply that the EBP model is simply in need of tweaking; that injustices are the unfortunate result of marginalised social groups “slipping through the cracks” (Berenstain et al., 2022), rather than a more inherent issue.
Oppression in EBP
While exploring epistemic injustices, nurse-researchers tend to avoid the notion of ‘epistemic oppression’ (Dotson, 2014) which involves the systematic discrediting of certain people as ‘knowers’ (with the capacity to form opinions and decisions) (Dotson, 2018). What has emerged from early modern race science, or ‘scientific racism’, is an example; it is designed to disenfranchise specific populations – Black and ethnically minoritised people, to the benefit of others – white Europeans (Sowemimo, 2023).
Systems of epistemic oppression promote certain areas of research and actively ignore others, something that is sometimes called ‘unknowing’ (Code, 2008), and this unknowing generates ‘silences’ (Dillard-Wright et al., 2023). There are many such ‘silences’ in health research, such as the continued lack of evidence around trans care (Rigby, 2025), and repeated failures to fully represent the production of knowledge, including, but not limited to, contributions from Black nurses (Dillard-Wright et al., 2023). In this sense, the injustices described are not merely accidental but designed.
Evidence-based practice relies on specific evidential hierarchies; Randomised Controlled Trials might be framed as a ‘gold standard’, while other forms of evidence, such as patient testimony and critique of theory, might be side-lined (Greenhalgh et al., 2015). Whilst the hierarchy can be tweaked, greater consideration must be given to ensure that methods of evidence generation are not more deeply compromised. Evidence showing that EBP is or is not unjust would need to meet the standards which are defined by the system itself; most critiques of EBP – including the texts referenced here – do not. It is for this reason, its structural avoidance of critique, that EBP should be approached with caution.
References
Berenstain, N., Dotson, K., Paredes, J., Ruíz, E. & Silva N.K. (2022) Epistemic oppression, resistance, and resurgence. Contemporary Political Theory 21:283–314 https://doi.org/10.1057/s41296-021-00483-z.
Blease, C., Carel, H. & Geraghty, K. (2017) Epistemic injustice in healthcare encounters: evidence from chronic fatigue syndrome. J Med Ethics 43:549–557 doi:10.1136/medethics-2016-103691.
Code, L. (2008) Advocacy, negotiation, and the politics of unknowing. The Southern Journal of Philosophy 46(1):32–51 https://doi.org/10.1111/j.2041-6962.2008.tb00152.x.
Dhairyawan, R. (2024) Unheard: the medical practice of silencing. Trapeze: Orion Publishing.
Dillard-Wright, J., Valderama-Wallace, C., Canty, L., Perron, A., De Sousa, I. & Gullick, J. (2023) What nursing chooses not to know: Practices of epistemic silence/silencing. Nursing Philosophy 24:e12443 https://doi.org/10.1111/nup.12443.
Dotson, K. (2014) Conceptualizing epistemic oppression. Social Epistemology 28(2):115–138.
Dotson, K. (2018) Accumulating epistemic power. Philosophical Topics 46(1):129–154.
Fu, Y., Wang, C., Hu, Y. & Muir-Cochrane, E. (2020) The barriers to evidence-based nursing implementation in mainland China: a qualitative content analysis. Nursing & Health Sciences, 22(4), 1038–1046. https://doi.org/10.1111/nhs.12763.
Greenhalgh, T., Snow, R., Ryan, S., Rees, S. & Salisbury, H. (2015) Six ‘biases’ against patients and carers in evidence-based medicine. BMC Medicine 13:200 doi 10.1186/s12916-015-0437-x.
Haghiri-Vijeh, R. (2025) Applying the concept of epistemic injustice as a philosophical window to examine discrimination experiences of LGBTQIA+ migrants with nurses. Nursing Philosophy 26(1), 26:e70007https://doi.org/10.1111/nup.70007.
Hanley, P., Chambers, B. & Haslam, J. (2016) Reassessing RCTs as the ‘gold standard’: synergy not separatism in evaluation designs. International Journal of Research & Method in Education, 39(3), 287–289 http://dx.doi.org/10.1080/1743727X.2016.1138457
Rigby, F. (2025) Trans people and the NHS: the heat of the debate needs the light of evidence. The King’s Fund Blog, https://www.kingsfund.org.uk/insight-and-analysis/blogs/trans-people-nhs-debate-evidence.
Sowemimo, A. (2023) Divided: racism, medicine and why we need to decolonise healthcare. Wellcome Collection publishing.